Background

The ileal pouch–anal anastomosis (IPAA) is a surgical procedure that is used to restore gastrointestinal continuity after surgical removal of the colon and rectum. Various conditions, including inflammatory states, cancer, or infection, may necessitate the complete surgical removal of the colon and rectum.

Also called a J pouch or an internal pouch, the procedure involves the creation of a pouch of small intestine to recreate the removed rectum. Two or more loops of intestine are sutured or stapled together to form a reservoir for stool. This reservoir is then attached to the anus for reestablishment of anal fecal flow. The IPAA is often protected by temporarily diverting the path of stool through the abdominal wall in the form of an upstream ileostomy. After a period of recovery, this ileostomy is reversed during a separate procedure.

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Indications

The IPAA procedure is performed after the colon and rectum have been completely removed. Removal of the colon and rectum is termed proctocolectomy. When an IPAA follows, the procedure is called a restorative proctocolectomy.
[1] Indications for restorative proctocolectomy include the following
[2] :

Contraindications

Creation of a J pouch is contraindicated when the small bowel is involved in the disease process. Such involvement is most common when proctocolectomy is performed for Crohn disease, because the distal ileum is often affected. IPAA is also contraindicated when the distal rectum or anal canal is diseased, as with Crohn disease or rectal cancer.

Concerns have been expressed about the safety of IPAA in older patients. A systematic review by Ramage et al found that the procedure was safe in this population, provided that the increased risk of dehydration and electrolyte loss was kept in mind.
[3] Older IPAA patients appeared to have worse postoperative function, but this impaired function seemed to level out over time, and there appeared to be no significant impact on overall quality of life and patient satisfaction.

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Technical Considerations

Complication prevention

Several standardized practices are followed to decrease the incidence of perioperative complications. Antibiotics are given within 1 hour of surgery to lower the rate of wound infection. Compression devices are placed on the legs to decrease the likelihood of blood clot formation. Patients are typically asked to stop taking any antiplatelet agents (eg, aspirin or clopidogrel) 1 week prior to surgery. This reduces bleeding complications.

Finally, before starting the surgical procedure, the surgeons, operating room staff, and anesthesia team should verify the correct patient and procedure in order to prevent errors.

Andrea C Bafford, MD Assistant Professor, Section of Colon and Rectal Surgery, Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center